肺结核合并2型糖尿病患者摄食因子leptin/ghrelin水平以及能量代谢特征研究
摘要
研究背景及目的：
2型糖尿病(T2DM)患者是肺结核病(TB)的高危人群,越来越多的研究提示T2DM是TB发生的重要危险因素,两病相互促进,使病情更加凶险。TB和T2DM的发生发展均可出现能量代谢紊乱。T2DM发生发展过程中出现高血糖和脂代谢紊乱,血循环中游离脂肪酸浓度增高,导致胰岛β细胞脂性凋亡和胰岛素分泌功能障碍。结核杆菌为了生长繁殖,会利用患者的能量物质进行菌体自身代谢,使得患者能量消耗增加,能量需求和蛋白质损失高于正常人群；结核杆菌菌体同时刺激引起炎性细胞因子分泌增多,直接作用于中枢神经系统的摄食中枢引起食欲减低,营养物质摄入减少导致合成代谢减少,易出现营养不良。两病共存,患者营养状况更复杂,代谢紊乱加剧。Leptin是食欲抑制因子,ghrelin是食欲刺激因子。Leptin/ghrelin是中枢能量平衡信息输入系统的两个互补因素,共同对食欲进行综合调节,并可能参与对炎性细胞因子表达水平的调节,leptin/ghrelin的不平衡与患者的食欲减低可能有密切联系。能量代谢酶活性的改变对能量代谢紊乱有重要影响,但是合并两种疾病后代谢酶活性的改变是否和单纯TB或者T2DM有区别,目前尚未有相关报道。B族维生素是体内多种能量代谢相关酶的辅酶,在调节机体能量代谢、预防和改善TB、T2DM等方面可能具有重要作用。TB患者因为食欲降低而导致B族维生素摄入减少,满足不了代谢酶合成的需求,也会加剧代谢紊乱。本研究通过选择TB合并T2DM患者作为研究对象,通过和TB、T2DM、巴胖患者以及正常人群对比,来系统了解TB合并T2DM患者体内摄食因子leptin/ghrelin水平变化和能量代谢的特征,并且探讨相关的影响因素及其与疾病发生发展的关系,为其临床诊疗与营养支持提供新思路。
研究方法：
采用流行病学横断面调查方法,根据横断面调查定量变量指标计算公式n=U1-2/a2S2/d2计算样本含量,在某地区结核病防治所和医院选择2011年7月-2013年7月纳入治疗的确诊肺结核患者(TB)40名、肺结核合并2型糖尿病患者(TB+T2DM)40名、糖尿病患者(T2DM)40名,同时在医院体检中心选择肥胖患者(体质指数BMI≥28)(OB)40名,正常对照组(C)76名,测量身高、体重。抽取空腹全血和静脉血,采用酶联免疫吸附法测定摄食因子leptin/ghrelin、炎性细胞因子水平,比色法测定全血和血浆代谢酶,留取晨尿采用荧光法进行B族维生素水平测定。
研究结果：
TB+T2DM组的空腹血糖值比T2DM组更高(9.51mM versus7.75mM,P<0.05),血脂和蛋白水平均低于其余组别。TB+T2DM组的血浆leptin水平要明显低于TB组(11.47ng/ml versus72.61ng/ml, P<0.05)却高于C组。TB+T2DM组的血浆TNF-a和IFN-y水平均为最高。对调查对象的BMI和摄食因子、炎性细胞因子等相关因素进行了相关性分析,显示TB+T2DM组、TB组的BMI和leptin呈明显的负相关(P<0.05),而在其余组别呈正相关。TB+T2DM组的ghrelin和BMI呈明显正相关(r=0.478,P<0.05)。多重线性回归分析结果显示TB+T2DM组的甘油三酯、leptin、 ghrelin、TNF-a是BMI的预测因子。多因素Logistic回归危险度分析结果显示低体重(BMI<18.5)发生TB+T2DM的风险是正常体重者的2.587倍(OR2.587,95%CI1.0-6.68). Leptin水平与TB+T2DM和TB的发病风险呈正相关,其最高四分位者患TB+T2DM的风险比最低四分位者要高50%左右(OR0.525,95%CI0.08-0.88),而ghrelin水平与TB+T2DM和TB的发病风险呈负相关,其最低四分位者患TB+T2DM的风险比最高四分位者要高10.605倍(OR10.605,95%CI2.15-52.24)。
TB+T2DM组的红细胞转酮醇酶活性系数(ETKac)和红细胞谷胱甘肽还原酶活性系数(EGRac)显著高于C组(38.12versus8.00, and1.23versus0.86, P<0.05),红细胞Na+-K+-ATP酶、血浆丙酮酸激酶(PK)、琥珀酸脱氢酶(SDH)活性均要低于C组。TB+T2DM组的维生素B1和维生素B2水平远低于C组(636.05versus976.56and425.24versus705.74, P<0.05)。TB+T2DM组的ETKac、EGRac和BMI呈负相关,PK、SDH和BMI呈显著的正相关(P<0.05). TB+T2DM组的ETKac%EGRac、维生素B1、维生素B2是BMI的预测因子。TB+T2DM组的ETKac和蛋白水平呈显著负相关(r=-0.363and r=-0.314, P<0.05),说明TK活性和机体的血清蛋白水平相关。TB+T2DM组的ETKac、EGRac和leptin水平呈显著正相关(r=0.304and r=0.209,P<0.05),其余能量代谢酶活性以及维生素B1和B2水平均和leptin水平均呈负相关,说明leptin水平升高引起的食欲减退对代谢酶活性和B族维生素水平有一定的影响。代谢酶活性和维生素B1和B2水平和TB+T2DM的发病风险均呈负相关,说明代谢酶和B族维生素是疾病的保护因素。
结论：
TB+T2DM患者体内摄食因子leptin/ghrelin水平出现紊乱,对炎性细胞因子的水平变化有一定影响。TB+T2DM患者能量代谢酶活性低下,作为代谢酶辅酶的B族维生素水平低,代谢酶活性和B族维生素水平与疾病发病风险相关。考虑TB+T2DM患者的营养不良(低BMI、低血脂和低血清蛋白水平)和leptin/ghrelin水平紊乱引起食欲减退,造成合成代谢酶的营养物质摄入减少而导致能量代谢功能失调有一定的关系。
Background and Objects:
Type2diabetes mellitus (T2DM) patients have a higher risk of acquiring pulmonary tuberculosis (TB), and T2DM may also impair TB treatment.TB and T2DM can cause metabolism disorder. T2DM occurred in hyperglycemia and lipid metabolism, free fatty acid concentrations may increase in blood circulation, resulting in pancreatic β cell apoptosis and dysfunction of insulin secretion. Mycobacterium tuberculosis use the energy of the patients for growth and reproduction, so TB patients may increase energy consumption, the energy demand and loss of protein is higher than normal. Mycobacterium tuberculosis can stimulate the secretion of inflammatory cytokines, which may direct effect feeding center in the central nervous system, cause poor appetite. Poor appetite reduce nutrient intake, lead to reduce anabolic reduction and prone to malnutrition. When TB combined T2DM, the nutritional status of patients is more complex. Leptin is an appetite suppressor, ghrelin is an appetite-stimulating factor. Leptin/ghrelin are two complementary factors in the energy balance of feeding center, which regulate appetite, and may participate in regulating the expression levels of inflammatory cytokines. Leptin/ghrelin imbalances may reduce the patient's appetite. Changes in metabolic enzyme activities has important effects on energy metabolism, but whether there are differences between TB combined T2DM and TB or T2DM only of metabolic enzyme activities remains unknown. B vitamins are cofactors of a variety of metabolic enzymes, involved in energy balance and have beneficial in TB and T2DM treatment. Because of decreased appetite, lead to reduce intakes of B vitamins in TB patients, and can not meet the needs of the metabolic enzyme synthesis, also exacerbate metabolic disorders. In this study, we selected pulmonary tuberculosis with type2diabetes patients, and TB, T2DM, obese patients and the normal population as study subjects, contrast to systematic understanding of leptin/ghrelin levels and energy metabolism characteristics in pulmonary tuberculosis with diabetes patients, also their related factors and relations with the disease, inorder to provide new ideas for clinical treatment and nutritional support.
Methods:
Used epidemiological cross-sectional survey method to choose40patients in an area of TB dispensaries and hospitals from July2011to July2013, who diagnosed as tuberculosis (TB), and40patients as pulmonary tuberculosis with type2diabetes (TB+T2DM),40type2diabetes (T2DM) patients, selected40obese patients (body mass index BMI≥28)(OB) and76normal control subjects (C) in a medical center. BMI, biochemical parameters and plasma levels of leptin, ghrelin, inflammatory cytokines and urine specimens levels of B vitamins were measured.
Results:
Fasting blood glucose levels of TB+T2DM group was higher than T2DM (9.51mM versus7.75mM, P<0.05). Levels of serum lipid and protein of TB+T2DM group were lower than C group. The levels of leptin were significantly lower in TB+T2DM than TB groups (11.47ng/ml versus72.61ng/ml, P<0.05). TB+T2DM group had the highest levels of plasma TNF-a and IFN-y. Leptin showed a negative correlation with BMI in TB+T2DM and TB groups (P<0.05), but a positive correlation with BMI in other groups. Contrary ghrelin showed a positive correlation with BMI in TB+T2DM group (r=0.478, P<0.05). Triglycerides, leptin, ghrelin, TNF-a were the predictive factors of BMI in TB+T2DM group.The riskratio of TB+T2DM was2.587fold (OR2.587,95%CI1.0-6.68) in low weight (BMI<18.5) compared with normal weight,1.5fold (OR0.525,95%CI0.08-0.88) in highest levels of leptin compared with lowest levels of leptin,10.605fold (OR10.605,95%CI2.15-52.24) in lowest levels of ghrelin compared with highest levels of ghrein.
Erythrocyte transketolase activity coefficient (ETKac) and erythrocyte glutathione reductase activity coefficient (EGRac) in TB+T2DM group was significantly higher than the C group (38.12versus8.00, and1.23versus0.86, P<0.05), erythrocyte Na+-K+-ATPase, plasma pyruvate kinase (PK), succinate dehydrogenase (SDH) activities were lower than C group. Levels of vitamin B1and vitamin B2in TB+T2DM group were significantly lower than C group (636.05versus976.56and425.24versus705.74, P<0.05).ETKac and ETKac showed a negative correlation with BMI, while PK and SDH showed a positive correlation with BMI in TB+T2DM group. ETKac, EGRac, vitamin B1and vitamin B2were the predictive factors of BMI in TB+T2DM group. ETKac showed a positive correlation with serum protein levels in TB+T2DM group (r=-0.363and r=-0.314, P<0.05), indicated that TK activites may relate to protein levels. ETKac and ETKac showed a positive correlation with leptin (r=0.304and r=0.209, P<0.05), while other metabolic enzymes and B vitamins were negative correlation with leptin, indicated high levels of leptin may reduce the patient's appetite, had an effect on enzyme activities and levels of B vitamins. Higher levels of enzyme activities and B vitamins may be beneficial to disease prevention.
Conclusions:
Imbalance of leptin/ghrelin may affect the expression levels of inflammatory cytokines. TB+T2DM group had lower levels of enzyme activities and B vitamins, which related to the risk of TB+T2DM. Poor nutrition of of TB+T2DM (low BMI, lower levels of serum lipids and proteins) may cause by poor appetite, which reduce nutrient intake and lead to reduce anabolic reduction.
2型糖尿病(T2DM)患者是肺结核病(TB)的高危人群,越来越多的研究提示T2DM是TB发生的重要危险因素,两病相互促进,使病情更加凶险。TB和T2DM的发生发展均可出现能量代谢紊乱。T2DM发生发展过程中出现高血糖和脂代谢紊乱,血循环中游离脂肪酸浓度增高,导致胰岛β细胞脂性凋亡和胰岛素分泌功能障碍。结核杆菌为了生长繁殖,会利用患者的能量物质进行菌体自身代谢,使得患者能量消耗增加,能量需求和蛋白质损失高于正常人群；结核杆菌菌体同时刺激引起炎性细胞因子分泌增多,直接作用于中枢神经系统的摄食中枢引起食欲减低,营养物质摄入减少导致合成代谢减少,易出现营养不良。两病共存,患者营养状况更复杂,代谢紊乱加剧。Leptin是食欲抑制因子,ghrelin是食欲刺激因子。Leptin/ghrelin是中枢能量平衡信息输入系统的两个互补因素,共同对食欲进行综合调节,并可能参与对炎性细胞因子表达水平的调节,leptin/ghrelin的不平衡与患者的食欲减低可能有密切联系。能量代谢酶活性的改变对能量代谢紊乱有重要影响,但是合并两种疾病后代谢酶活性的改变是否和单纯TB或者T2DM有区别,目前尚未有相关报道。B族维生素是体内多种能量代谢相关酶的辅酶,在调节机体能量代谢、预防和改善TB、T2DM等方面可能具有重要作用。TB患者因为食欲降低而导致B族维生素摄入减少,满足不了代谢酶合成的需求,也会加剧代谢紊乱。本研究通过选择TB合并T2DM患者作为研究对象,通过和TB、T2DM、巴胖患者以及正常人群对比,来系统了解TB合并T2DM患者体内摄食因子leptin/ghrelin水平变化和能量代谢的特征,并且探讨相关的影响因素及其与疾病发生发展的关系,为其临床诊疗与营养支持提供新思路。
研究方法：
采用流行病学横断面调查方法,根据横断面调查定量变量指标计算公式n=U1-2/a2S2/d2计算样本含量,在某地区结核病防治所和医院选择2011年7月-2013年7月纳入治疗的确诊肺结核患者(TB)40名、肺结核合并2型糖尿病患者(TB+T2DM)40名、糖尿病患者(T2DM)40名,同时在医院体检中心选择肥胖患者(体质指数BMI≥28)(OB)40名,正常对照组(C)76名,测量身高、体重。抽取空腹全血和静脉血,采用酶联免疫吸附法测定摄食因子leptin/ghrelin、炎性细胞因子水平,比色法测定全血和血浆代谢酶,留取晨尿采用荧光法进行B族维生素水平测定。
研究结果：
TB+T2DM组的空腹血糖值比T2DM组更高(9.51mM versus7.75mM,P<0.05),血脂和蛋白水平均低于其余组别。TB+T2DM组的血浆leptin水平要明显低于TB组(11.47ng/ml versus72.61ng/ml, P<0.05)却高于C组。TB+T2DM组的血浆TNF-a和IFN-y水平均为最高。对调查对象的BMI和摄食因子、炎性细胞因子等相关因素进行了相关性分析,显示TB+T2DM组、TB组的BMI和leptin呈明显的负相关(P<0.05),而在其余组别呈正相关。TB+T2DM组的ghrelin和BMI呈明显正相关(r=0.478,P<0.05)。多重线性回归分析结果显示TB+T2DM组的甘油三酯、leptin、 ghrelin、TNF-a是BMI的预测因子。多因素Logistic回归危险度分析结果显示低体重(BMI<18.5)发生TB+T2DM的风险是正常体重者的2.587倍(OR2.587,95%CI1.0-6.68). Leptin水平与TB+T2DM和TB的发病风险呈正相关,其最高四分位者患TB+T2DM的风险比最低四分位者要高50%左右(OR0.525,95%CI0.08-0.88),而ghrelin水平与TB+T2DM和TB的发病风险呈负相关,其最低四分位者患TB+T2DM的风险比最高四分位者要高10.605倍(OR10.605,95%CI2.15-52.24)。
TB+T2DM组的红细胞转酮醇酶活性系数(ETKac)和红细胞谷胱甘肽还原酶活性系数(EGRac)显著高于C组(38.12versus8.00, and1.23versus0.86, P<0.05),红细胞Na+-K+-ATP酶、血浆丙酮酸激酶(PK)、琥珀酸脱氢酶(SDH)活性均要低于C组。TB+T2DM组的维生素B1和维生素B2水平远低于C组(636.05versus976.56and425.24versus705.74, P<0.05)。TB+T2DM组的ETKac、EGRac和BMI呈负相关,PK、SDH和BMI呈显著的正相关(P<0.05). TB+T2DM组的ETKac%EGRac、维生素B1、维生素B2是BMI的预测因子。TB+T2DM组的ETKac和蛋白水平呈显著负相关(r=-0.363and r=-0.314, P<0.05),说明TK活性和机体的血清蛋白水平相关。TB+T2DM组的ETKac、EGRac和leptin水平呈显著正相关(r=0.304and r=0.209,P<0.05),其余能量代谢酶活性以及维生素B1和B2水平均和leptin水平均呈负相关,说明leptin水平升高引起的食欲减退对代谢酶活性和B族维生素水平有一定的影响。代谢酶活性和维生素B1和B2水平和TB+T2DM的发病风险均呈负相关,说明代谢酶和B族维生素是疾病的保护因素。
结论：
TB+T2DM患者体内摄食因子leptin/ghrelin水平出现紊乱,对炎性细胞因子的水平变化有一定影响。TB+T2DM患者能量代谢酶活性低下,作为代谢酶辅酶的B族维生素水平低,代谢酶活性和B族维生素水平与疾病发病风险相关。考虑TB+T2DM患者的营养不良(低BMI、低血脂和低血清蛋白水平)和leptin/ghrelin水平紊乱引起食欲减退,造成合成代谢酶的营养物质摄入减少而导致能量代谢功能失调有一定的关系。
Background and Objects:
Type2diabetes mellitus (T2DM) patients have a higher risk of acquiring pulmonary tuberculosis (TB), and T2DM may also impair TB treatment.TB and T2DM can cause metabolism disorder. T2DM occurred in hyperglycemia and lipid metabolism, free fatty acid concentrations may increase in blood circulation, resulting in pancreatic β cell apoptosis and dysfunction of insulin secretion. Mycobacterium tuberculosis use the energy of the patients for growth and reproduction, so TB patients may increase energy consumption, the energy demand and loss of protein is higher than normal. Mycobacterium tuberculosis can stimulate the secretion of inflammatory cytokines, which may direct effect feeding center in the central nervous system, cause poor appetite. Poor appetite reduce nutrient intake, lead to reduce anabolic reduction and prone to malnutrition. When TB combined T2DM, the nutritional status of patients is more complex. Leptin is an appetite suppressor, ghrelin is an appetite-stimulating factor. Leptin/ghrelin are two complementary factors in the energy balance of feeding center, which regulate appetite, and may participate in regulating the expression levels of inflammatory cytokines. Leptin/ghrelin imbalances may reduce the patient's appetite. Changes in metabolic enzyme activities has important effects on energy metabolism, but whether there are differences between TB combined T2DM and TB or T2DM only of metabolic enzyme activities remains unknown. B vitamins are cofactors of a variety of metabolic enzymes, involved in energy balance and have beneficial in TB and T2DM treatment. Because of decreased appetite, lead to reduce intakes of B vitamins in TB patients, and can not meet the needs of the metabolic enzyme synthesis, also exacerbate metabolic disorders. In this study, we selected pulmonary tuberculosis with type2diabetes patients, and TB, T2DM, obese patients and the normal population as study subjects, contrast to systematic understanding of leptin/ghrelin levels and energy metabolism characteristics in pulmonary tuberculosis with diabetes patients, also their related factors and relations with the disease, inorder to provide new ideas for clinical treatment and nutritional support.
Methods:
Used epidemiological cross-sectional survey method to choose40patients in an area of TB dispensaries and hospitals from July2011to July2013, who diagnosed as tuberculosis (TB), and40patients as pulmonary tuberculosis with type2diabetes (TB+T2DM),40type2diabetes (T2DM) patients, selected40obese patients (body mass index BMI≥28)(OB) and76normal control subjects (C) in a medical center. BMI, biochemical parameters and plasma levels of leptin, ghrelin, inflammatory cytokines and urine specimens levels of B vitamins were measured.
Results:
Fasting blood glucose levels of TB+T2DM group was higher than T2DM (9.51mM versus7.75mM, P<0.05). Levels of serum lipid and protein of TB+T2DM group were lower than C group. The levels of leptin were significantly lower in TB+T2DM than TB groups (11.47ng/ml versus72.61ng/ml, P<0.05). TB+T2DM group had the highest levels of plasma TNF-a and IFN-y. Leptin showed a negative correlation with BMI in TB+T2DM and TB groups (P<0.05), but a positive correlation with BMI in other groups. Contrary ghrelin showed a positive correlation with BMI in TB+T2DM group (r=0.478, P<0.05). Triglycerides, leptin, ghrelin, TNF-a were the predictive factors of BMI in TB+T2DM group.The riskratio of TB+T2DM was2.587fold (OR2.587,95%CI1.0-6.68) in low weight (BMI<18.5) compared with normal weight,1.5fold (OR0.525,95%CI0.08-0.88) in highest levels of leptin compared with lowest levels of leptin,10.605fold (OR10.605,95%CI2.15-52.24) in lowest levels of ghrelin compared with highest levels of ghrein.
Erythrocyte transketolase activity coefficient (ETKac) and erythrocyte glutathione reductase activity coefficient (EGRac) in TB+T2DM group was significantly higher than the C group (38.12versus8.00, and1.23versus0.86, P<0.05), erythrocyte Na+-K+-ATPase, plasma pyruvate kinase (PK), succinate dehydrogenase (SDH) activities were lower than C group. Levels of vitamin B1and vitamin B2in TB+T2DM group were significantly lower than C group (636.05versus976.56and425.24versus705.74, P<0.05).ETKac and ETKac showed a negative correlation with BMI, while PK and SDH showed a positive correlation with BMI in TB+T2DM group. ETKac, EGRac, vitamin B1and vitamin B2were the predictive factors of BMI in TB+T2DM group. ETKac showed a positive correlation with serum protein levels in TB+T2DM group (r=-0.363and r=-0.314, P<0.05), indicated that TK activites may relate to protein levels. ETKac and ETKac showed a positive correlation with leptin (r=0.304and r=0.209, P<0.05), while other metabolic enzymes and B vitamins were negative correlation with leptin, indicated high levels of leptin may reduce the patient's appetite, had an effect on enzyme activities and levels of B vitamins. Higher levels of enzyme activities and B vitamins may be beneficial to disease prevention.
Conclusions:
Imbalance of leptin/ghrelin may affect the expression levels of inflammatory cytokines. TB+T2DM group had lower levels of enzyme activities and B vitamins, which related to the risk of TB+T2DM. Poor nutrition of of TB+T2DM (low BMI, lower levels of serum lipids and proteins) may cause by poor appetite, which reduce nutrient intake and lead to reduce anabolic reduction.
引文
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